TRIGEMINAL NERVE

GUIDED BY- PRESENTED BY-

DR. ASHISTARU SAHA DR. POOJA AGRAWAL
DR. ANUPAM PURWAR
DR. TUSHAR TANWANI
DR. PRANAY MAHASETH
DR. NEVA NAVLANI
CONTENT
 INTRODUCTION

 CLASSIFICATION OF CRANIAL NERVE

 EMBRYOLOGY OF TRIGEMINAL NERVE

 NUCLEI OF TRIGEMINAL NERVE

 DIVISON – OPHTHALMIC NERVE

MAXILLARY NERVE

MANDIBULAR NERVE
 ASSOCIATED GANGLIA
 APPLIED ANATOMY

 CONCLUSION
INTRODUCTION
 Nerve- A bundle of fibres that uses electrical and
chemical signals to transmit sensory and motor
information from one body part to another.

 Nervous system-The nervous system is the part of

an animal's body that coordinates its actions and
transmits signals to and from different parts of its body.
 Nervous system consists of two main parts-
  Central nervous system(CNS)
 Peripheral nervous system(PNS)

 Nerves that exit from the cranium are called cranial

nerves while those exiting from the spinal cord are
called spinal nerves.
 Cranialnerves- Cranial nerves are the nerves that
emerge directly from the brain.

 Twelve pairs of cranial nerves.

 Trigeminal nerve is fifth cranial nerve.

NERVE IN ORDER
Cranial Nerve I - Olfactory
Cranial Nerve II - Optic
Cranial Nerve III - Occulomotor
Cranial Nerve IV - Trochlear
Cranial Nerve V - Trigeminal
Cranial Nerve VI - Abducens
Cranial Nerve VII - Facial
Cranial Nerve VIII- Vestibulocochlear
Cranial Nerve IX - Glossopharyngeal
Cranial Nerve X - Vagus
Cranial Nerve XI - Spinal Accessory
Cranial Nerve XII - Hypoglossal
CLASSIFICATION OF CRANIAL NERVES
 Sensory cranial nerves: contain only afferent (sensory) fibers
◦ ⅠOlfactory nerve
◦ ⅡOptic nerve
◦ Ⅷ Vestibulocochlear nerve
 Motor cranial nerves: contain only efferent (motor) fibers
◦ Ⅲ Oculomotor nerve
◦ Ⅳ Trochlear nerve
◦ ⅥAbducent nerve
◦ Ⅺ Accessory nerve
◦ Ⅻ Hypoglossal nerve
 Mixed nerves: contain both sensory and motor fibers
◦ ⅤTrigeminal nerve,
◦ Ⅶ Facial nerve,
◦ ⅨGlossopharyngeal nerve
◦ ⅩVagus nerve
EMBRYOLOGY OF THE NERVE
• During the development of embryo, the pharyngeal
arches appear in the fourth and fifth week.
• It give rise to six pharyngeal arches, of which the 5th
arch disappears.
 Each arch is characterized by its own:

 muscular component

 nerve component

 arterial component

 skeletal component

• Trigeminal nerve is derived from 1st pharyngeal arch

Musculature of the first pharyngeal arch includes:-
1. Muscles of mastication :
Temporalis
Masseter
Pterygoids

2. Anterior belly of diagastric

3. Mylohyoid

4. Tensor tympani

5.Tensor palatini

The nerve supply to these muscles is provided by mandibular

division of trigeminal nerve.
 Mesenchyme from the 1st arch also contributes to
the dermis of the face, hence sensory supply to the
skin of the face is provided by ophthalmic,
maxillary and mandibular branches of the
trigeminal nerve.
Nuclei of trigeminal nerve-
 It has got 4 nuclei :

1) Main sensory nuclei

2) Spinal nuclei SENSORY

3) Mesencephalic nuclei

4) Motor nuclei
THE TRIGEMINAL GANGLION -
 Also known as Gasserian ganglion, or semilunar
ganglion, is a sensory ganglion of the trigeminal nerve
that occupies a cavity (Meckel's cave) in the dura mater,
covering the trigeminal impression near the apex of
the petrous part of the temporal bone.
TRIGEMINAL NERVE
• Trigeminal nerve is the largest cranial nerve.

• It is a mixed nerve.

• Composed of a small motor root and a considerably

larger sensory root.

• 3 divisons of trigeminal nerve- Ophthalmic (Sensory)

Maxillary (Sensory)
Mandibular (Mixed)
THE OPHTHALMIC DIVISION-
 Smallest of all three branches.
 Sensory only
 Supplies : eyeballs, conjunctiva, lacrimal gland, mucosa
of nose and paranasal sinus, skin of forehead eyelid and
nose.
 Ophthalmic divison divides into 3 branches-
Lacrimal nerve
Frontal nerve
Nasiciliary nerve
LACRIMAL NERVE
 Smallest of three branches.
 It supplies sensory innervation to lacrimal gland and
conjunctiva.
FRONTAL NERVE
 Largest of three branches.
 At about middle of orbit, frontal nerve divides into two
branches-

Supraorbital Nerve

Supratrochlear Nerve
• Supraorbital Nerve- Largest branch

It supplies the skin of the upper eyelid, the forehead, and

the anterior scalp region to the vertex of skull.
• Supratrochlear Nerve- Smallest branch.

It supplies skin of upper eyelid and lower medial portion

of the forehead.
 NASOCILIARY NERVE

In orbit In Nasal cavity In face

Long root Long ciliary Posterior ethmoid Anterior

Of ciliary nerve nerve ethmoid
Ganglion

Internal nasal External nasal

Medial Lateral
MAXILLARY NERVE
 Entirely sensory in function.
 It gives off branches in four regions-

In middle cranial fossa

In pterygopalatine fossa

In infraorbital groove

Face
 COURSE- Middle of semilunar ganglion

Lower part of cavernous sinus

Foramen rotundum

Pterygopalatine fossa

Inferior orbital fissure

orbital surface of maxilla

Infraorbital foramen
IN MIDDLE CRANIAL FOSSA-

- Meningeal branch: Travels along the middle meningeal

artery and provides sensory innervation to cranial dura
matter.
 IN PTERYGOPALATINE FOSSA

Zygomatic nerve Pterygopalatine Posterior superior

nerves alveolar branches

Zygomaticofacial Orbital
Posterior sup lat nasal
Zygomaticotemporal Nasal
Medial
Palatine

Greater Middle Posterior

palatine palatine palatine
 IN INFRAORBITAL GROOVE

Middle superior alveolar Anterior superior alveolar

nerve nerve

Supplies maxillary bicuspids. Supplies labial gingivae

of the incisors and cuspid
teeth.
 TERMINAL BRANCHES IN FACE

Inferior palpebral Lateral nasal Superior

labial
branches branches branches

Supplies skin of lower skin of side of skin and mucous

Eyelid and conjunctiva nose membrane of
upper lip
MANDIBULAR NERVE
• Largest division of trigeminal nerve
• Mixed in nature. It Has a large sensory root and a small
motor root.
• The sensory root originates from trigeminal ganglion
whereas the motor root originates in the pons and
medulla oblongata.
• The two roots emerge from the cranium separately
through the foramen ovale, the motor root lying medial
to sensory. they unite just outside the skull and form the
main trunk of 3rd division.
 BRANCHES OF THE UNDIVIDED NERVE:

On leaving the foramen ovale the main undivided trunk

gives two branches during its 2-3mm course ie the
meningeal branch and the nerve to medial pterygoid

1. THE MENINGEAL BRANCH

Also called as Nervus Spinosus.

It re-enters the cranium through the foramen spinosum

along with the middle meningeal artery to supply the
duramater.
2. NERVE TO MEDIAL PTERYGOID

It is a motor nerve to medial pterygoid muscle

It supplies one or two filaments which passes through

otic ganglion to supply tensor tympani and tensor veli
palatini.
BRANCHES FROM ANTERIOR DIVISION:
 Provides motor innervation to the muscles of
mastication ,sensory innervation to the mucous
membrane of the cheek and buccal mucous membrane
of the mandibular molars.
 The anterior division is smaller than the posterior
division.It runs forward under the lateral pterygoid
muscle for a short distance and then reaches the external
surface of that muscle by passing between its two
heads, from this point it is known as buccal nerve.
 Underthe lateral pterygoid nerve,it gives off some
branches, i.e.

The deep temporal nerve- to the temporal muscle

The masseter nerve- providing motor innervation to

masseter muscle

Lateral pterygoid nerve- providing motor innervation to

the lateral pterygoid muscle
 Buccal nerve- This branch supplies sensory fibers to the
buccal gingivae about the mandibular molars and the
mucous membrane of the lower part of the buccal
vestibule.
BRANCHES FROM POSTERIOR DIVISON-

 Auriculotemporal nerve- It divides into numerous

branches, to the tragus of the pinna of the external ear, to
the scalp about ear and as far upward as the vertex of
skull.
 Branches-
 Parotid branches
 Articular branches
 Auricular branches
 Meatal branches
 Terminal branches
 Lingual nerve- The lingual nerve contributes many
sensory fibers to the mucous membrane of the floor of
mouth and gingiva on the lingual surface of the
mandible.
 Inferior alveolar nerve- Largest branch of the
mandibular division.

 It divides into two branches at the region of mental

foramen-

Mental nerve Incisive nerve

• Before entering into mandibular foramen it gives off
mylohyoid branch.
GANGLIA ASSOCIATED WITH THE
TRIGEMINAL NERVE
1.CILLIARY GANGLION
 connected with nasocilliary nerve by ganglionic
branches in orbit, non synapsing
 sensory for orbit
 2.PTERYGOPALATINE GANGLION:
connected to maxillary nerve in infratemporal fossa
sensory to orbital septum, orbicularis and nasal cavity,
maxillary sinus , palate , nasopharynx.
 3.OTIC GANGLION: lies between trunk of
mandibular nerve and tensor palatini , nerve to medial
pterygoid passes through but does not synapse in the
ganglion.
 4.SUBMANDIBULAR GANGLION: related to lingual
nerve,rest on hypoglossus .
supplies posterior ganglionic Parasympathetic
secretomotor fibres to submandibular and sublingual
gland.
APPLIED ANATOMY -
 Trigeminal neuralgia

 Trigeminal neuropathy

 Herpes zoster ophthalmicus

TRIGEMINAL NEURALGIA
Trigeminal neuralgia
 also known as Fothergill’s disease
Tic douloureux (painful jerking)
 it is defined as ,
sudden ,usually ,unilateral ,severe ,brief ,stabbing ,
lancinating , recurring pain in the distribution of one or
more branches of trigeminal nerve.
 Mean age: 50 y onwards
 Female predominance (male : female = 1:2 ~2:3)
Pathogenesis of trigeminal neuralgia
 It is usualy idiopathic.

 The probable etiologic factors are:-

Intra cranial tumors:-Traumatic compression of the

trigeminal nerve by neoplastic (cerebellopontine angle
tumor) or vascular anomalies eg arteriovenous
malformations

Infections :- granulomatous and non granulomatous

infections involving 5th cranial nerve.
General characteristics
 Incidence:- seen in about 4 in 100000 persons

 Age of occurrence:- 5th to 6th decade

 Sex predilection:-female predisposition

 Side involved more frequently:-right side

 Division
of trigeminal nerve involve; most commonly
mandibular > maxillary >ophthalmic
Clinical characteristics:-
 Sudden

 Unilateral

 intermittent paroxysmal

 sharp shooting

 lancinating shock like pain elicted by slight touching

 presence of intraoral or extraoral trigger points
TREATMENT:
 Medical treatment

 Surgical treatment
Medical treatment
 Carbamazepine and phenytoin are the traditional
anticonvulsants given primarily.

 Thedosage of the drug used initially should be kept

small to minimum especially in elderly patients to avoid
nausea, vomiting and gastric irritation.

 Dosageshould be taken at night so that adequate serum

concentration is present early morning.
Surgical treatment
Peripheral injections

Peripheral neurectomy

Cryotherapy

 Peripheral radiofrequency

 Neurolysis(thermocoagulation)

 Gasserian ganglion procedures

 TRIGEMINAL NEUROPATHY
 Facial pain resulting from unintentional injury to the
trigeminal system from facial trauma, oral surgery, ear, nose
and throat (ENT) surgery, root injury from posterior fossa
or skull base surgery, stroke, etc.
 This pain is described as dull, burning, or boring and is
usually constant because the injured nerve spontaneously
sends impulses to the brain.
 The injured nerve is also hypersensitive to stimulation, so
attacks of sharp pain can also be present. The area which is
sensitive to touch and triggers these sharp attacks is the
same area where the pain occurs. Numbness and tingling
are also signs of a damaged nerve.
TREATMENT
 Trigeminal neuropathic pain is usually a long-term
condition. It is unlikely that any treatments will
completely remove the symptoms. Therefore treatment
focuses on reducing symptoms and helping you to

manage the condition.

HERPES ZOSTER OPHTHALMICUS
 Caused by Varicella zoster virus
Predilection for nasociliary branch of ophthalmic
division of the trigeminal nerve.

 CLINICAL FEATURES:-
Cutaneous lesions:-

Rash

Vesicle

Pustule crust permanent scar

 Ocular lesions:-
Eyelid:- Perorbital pain
Oedema
Hyperasthesia
Conjunctivitis

Scleritis
Corneal scarring
Glaucoma
TREATMENT
 Acyclovir 800mg 5 times /day within 4 days of onset
of rash
 Analgesics

 Antibiotic ointments

 Systemic steroids 60mg/day

 Corneal grafting
CONCLUSION
 Trigeminal nerve, its anatomic course and branches are
very important from a dentist point of view as
inadvertant surgical procedure may lead to trigeminal
nerve injury.

 Disorders of Trigeminal nerve are not rare ,knowing

about it will help in formulating appropriate diagnosis
and treatment thus achieving the best possible recovery
of Trigeminal nerve function.
REFRENCES
 Bennnet CR. Monheim’s local anaesthesia and pain
control in dental practice. 7th edition.
 Chaurasia BD. Human anatomy volume 3. 6th edition.
 Snell RS. Clinical anatomy by regions. 8th edition.
 Kazi SN. Anatomy.